Breast reconstruction

breast reconstruction

Breast reconstruction is the creation of a new breast after a mastectomy or breast removal due to breast disease breast reconstruction re stores the form of the breast and the mound of the breast and it has been proven that it has major benefits for women after mastectomy in terms of their psychology, self-esteem and their quality of life however although the skin of the breast is the regular patience skin , the breast that is created does not contain breast glands and regular breast tissue but it contains either tissue from another part of the body or silicone. Additionally every effort is made in order to achieve a symmetrical breast compared to the other side and many women’s breasts look even better after reconstruction than they did before.

Breast reconstruction is performed with modern surgical techniques in a safe manner in order to achieve the optimal result with the least possible surgery. Breast reconstruction can be performed at the time of the mastectomy or at a later time and this depends on several factors. Also, it can be performed in a single stage or in two or more stages depending on the type of reconstruction and the type of the mastectomy that was performed. With the surgical techniques that we use today we aim to minimize the requirement for additional surgeries helping patients to move forward as soon as possible. We therefore usually reconstruct the breast in a single operation at the same time with the mastectomy.

Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, seems to have been eliminated by mastectomy.

Still, there are legitimate reasons to wait. Many women aren’t comfortable weighing all the options while they’re struggling to cope with a diagnosis of cancer. Others simply don’t want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait.

In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a more positive outlook for the future.

The two main categories of breast reconstruction in terms of the timing of the reconstruction and the following:

  • The immediate reconstruction during which the new breast is created at the time of the mastectomy and
  • The delayed breast reconstruction which is performed months or years after a mastectomy.

Any surgical technique (implant or flap or combination) can be performed during the immediate or during the delayed reconstruction.

Immediate reconstruction: During the immediate breast reconstruction a single surgery a single surgery is performed in which both the mastectomy and the reconstruction is performed at the same time. If all the skin is preserved then a complete reconstruction can be performed with no need for further stages. However if not enough skin is available after the mastectomy or the quality of the skin is not good (smokers), then the first stage is performed in an an immediate fashion and the second stage is performed 46 months later.Women undergoing prophylactic must act to me to decrease their cancer risk due to family history aregreat candidates for immediate breast reconstruction. However women with more advanced disease like large tumors or tumors that will require radiation are usually not candidates for immediate breast reconstruction

Delayed reconstruction: In this case the breast reconstruction is performed several months or a year after the mastectomy, depending and the individual patient’s medical situation, especially in terms of her radiation treatments.

There are three types of breast reconstruction in terms of surgical technique:

  1. Silicone implant breast reconstruction
  2. Autologous reconstruction where your own tissue is utilized (flap surgery)
  3. Combination of both (1 & 2)

Silicone implant breast reconstruction
This is by far the most common method of breast reconstruction. Breast implants can be placed:

  • In one stage, during the mastectomy, if enough skin is available:
    Implants are placed during the mastectomy surgery in order to create the new breast directly. This is a newer technique that we use very frequently and Is suitable for women who are having skin-sparing or nipple-sparing mastectomy where most of the breast skin is preserved. The implant is placed under the chest muscle (sub-pectoral) or over the chest muscle (pre-pectoral) and a special mesh is also used in order to stabilize and cover the implant. The biological mesh is called Acellular Dermal Matrix (ADM) and it covers the lower implant in the under-muscle technique (sub-pectoral) and the entire implant in the over-the-muscle technique (pre-pectoral), or
  • In two stages if not enough skin is available:
    This is the more traditional approach. During the first stage a temporary breast expander is placed under the chest muscle and skin. This can be done during the mastectomy or in a delayed fashion months later. The expander is a silicone “balloon” that inflates with saline (salt water) that we inject through a valve in order to expand and stretch the skin. After the skin of the breast has been fully stretched to achieve the desired size and shape , the second stage is undertaken to exchange the expander with a permanent silicone implant.

Autologous reconstruction where your own tissue is utilized (flap surgery)
During the autologous breast reconstruction the breast is created from the patient’s own body tissues that are transferred to the breast area. The medical term for the transferred tissue is “flap”. The flap may contain skin, fat and sometimes muscle. The areas from where the patient’s tissues are used are usually “extcess tissue” areas such as the lower abdomen or the buttocks or the thigh. The tissue is removed from those areas and transferred to the mastectomy area and is subsequently shaped to form a new breast. The advantage of this type of reconstruction is that it permits creation of a natural breast ptosis (natural breast droopiness) and that the transferred tissue adjusts to the changes in the body weight. We must mention that these procedures are surgically more complex than implant-based reconstructions and frequently require blood vessel microscopic connections in order to complete. Some autologous reconstructions require many hours of surgery and they pose significant potential complications. The autologous reconstruction procedures can be performed directly during the mastectomy as an immediate reconstruction or several months later as a delayed reconstruction. They are an excellent option for women who wish to avoid breast implants.

Combination technique (implant and autologous reconstruction)
Sometimes the combination of both techniques is required in order to complete a breast reconstruction. In these cases a silicone breast implant is placed and also autologous muscle tissue (usually latissimus dorsi muscle from the back) is used. Usually the indication for this combination is the need for radiotherapy after the mastectomy. This technique is usually performed in a delayed fashion, several months after the mastectomy what may also be performed in an immediate fashion.

There are several factors that determined the exact technique that will be used for breast reconstruction like your body shape and pre existing breast size your preference in terms of breast shape and size your overall health and especially whether you smoke, the quality of the remaining skin after a mistake to me and others a very important factor is also whether you will need radiotherapy or not or you have already had radiotherapy treatment.

If chemotherapy is given before the mastectomy in order to shrink the tumor then usually the mastectomy is scheduled six weeks after chemotherapy is over. This is performed in order to allow the body to recover adequately. If chemotherapy is performed after the mastectomy usually it starts at least 3-12 weeks after the surgery in order for the wound healing to complete and for the incisions to seal. We must mention that if expanders are placed they can be inflated during this time without problems.

Radiotherapy can significantly affect the breast and chest area as it causes fibrosis (scarring) that makes the tissues firmer and more resistant to changes. It is advisable that at least six months must pass after the completion of radiation before any breast reconstruction can occur. During this time the radiation skin changes and the radiation swelling gradually resolves. In some cases permanent changes under the skin may happen, like darkening or change and thickness and texture of the skin. These changes may significantly influence the type of reconstruction that is best for the patient and usually a flap technique is necessary if the mastectomy area has been irradiated. If radiation is planned after your mastectomy then one option is to not perform the immediate reconstruction and to delay it for six months to a year after the mastectomy. However with the modern surgical techniques and radiation techniques an immediate reconstruction can still be done even if radiation is planned after the mastectomy. Radiation usually does not affect the flap tissue reconstruction Although it can shrink the tissue in some cases depending on the radiation dosage. If breast implants were used and subsequently the area was irradiated , as long as the implant is fully inflated prior to the radiation , they should maintain their shape in the long term. keep in mind that it may take up to a year or more for the full effects of radiation changes to be evident and sometimes radiation changes may show up years after a breast reconstruction. If their reconstruction changes significantly there is always the option to correct any residual deformity usually by a minor surgical procedure like fat transfer.

If you have a nipple-sparing mastectomy there is obviously no need to create a new nipple as your own nipple is preserved. For mastectomies that remove the nipple a formal nipple reconstruction is performed approximately 3-4 months after your breast reconstruction in order to allow healing to occur and for the breast to assume it’s final shape and position. The nipple creation procedure is a minor procedure that can be performed under local anesthesia in order to create the central nipple prominence and it is the final step in the surgical restoration of the breast. There are several techniques available for nipple reconstruction and they all involve using local breast skin in order to create a small central mound which is approximately the same size as the other nipple. Finally the areola is created approximately 3 months after the nipple reconstruction. This is done with a tattoo treatment which places the dye inside the skin of the nipple and around it in order to recreate the appearance of a natural nipple . The areola creation is also done as an outpatient office procedure.

The most important aspect of breast reconstruction from a cosmetic point of view is creating a natural breast that fits the frame of your body but also achieving breast symmetry compared to the other side. Every surgical effort is always made in order to achieve it but we know that it is not possible to achieve absolute symmetry. Although for some women the difference between the reconstructed breast and their remaining breast is not noticeable, for many others the difference may be quite noticeable. Therefore many women decide to have a symmetry surgical procedure on the remaining breast in order to enlarge the breast (breast augmentation) or to make it smaller (breast reduction) or a breast lift (mastopexy procedure). This is usually performed as a delayed procedure during the second stage of breast reconstruction or as a separate procedure.

breast reconstruction 1

Breast reconstruction is a very individualized procedure and every case is different. No single procedure is right for everyone and every woman’s body type and preferences are different. The most appropriate reconstructive option considers a woman’s desires, her anatomy, her lifestyle and her specific medical situation. The goal is always to create a beautiful, natural and long lasting breast reconstruction.